Provider Demographics
NPI:1124066311
Name:BURKE, JONATHAN S (D D S)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:S
Last Name:BURKE
Suffix:
Gender:M
Credentials:D D S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 E JOLIET ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-4724
Mailing Address - Country:US
Mailing Address - Phone:219-662-9932
Mailing Address - Fax:219-663-9688
Practice Address - Street 1:1410 E JOLIET ST
Practice Address - Street 2:SUITE D
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-4724
Practice Address - Country:US
Practice Address - Phone:219-662-9932
Practice Address - Fax:219-663-9688
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120098501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN12009850OtherLICENSE NUMBER